During an assessment under our new approach
Date of assessment: 15 April to 7 May 2026
This inspection was undertaken in response to identified risks arising from individual cases and emerging patterns of concern. The findings identified during the inspection highlighted further areas of risk, requiring an expanded and more detailed review.
The service was not providing consistently good care. Weaknesses in care planning and risk management meant people were exposed to avoidable harm, as changes in need were not always identified or acted on promptly.
Medicines were not always managed safely, with records showing missed doses, delays in administering time‑critical medicines which increased the risk of harm.
Systems intended to monitor quality and safety were in place but were not used effectively to highlight concerns or trigger timely action. As a result, learning from incidents, audits and feedback did not consistently lead to improvement. Leadership and governance arrangements lacked stability and effective oversight, which limited accountability when issues were identified.
Staffing pressures further affected the service’s ability to deliver safe and consistent care, and staff were not always supported through effective supervision or development.
Although the provider had begun to take steps to address leadership, governance and workforce concerns, these actions were at an early stage and had not yet resulted in sustained improvement at the time of inspection.
The provider was in breach of the legal regulations relating to safe care and treatment and good governance.